Letter

SIR m Re: O'Neill TW, Marsden D, Silman A J, and the European Vertebral Osteoporosis Study Group. Differences in the characteristics of responders and non-responders in a prevalence survey of vertebral osteoporosis. Osteoporosis Int 1995;5:32%34. It is unfortunate that Dr O'Neill et al., in their review of the influence of non-response bias on osteoporosis studies [1], did not include our report on the subject [2]. As O'Neill et al. point out, there have been few population-based investigations of this issue. However, our study was not only population-based but was the only one able to assess the baseline characteristics of all of the non-responders in the community. Our experience provides somewhat different insights than those reported by O'Neill et al. from the European Vertebral Osteoporosis Study (EVOS). First, the apparent influence of referral bias on the European Vertebral Osteoporosis Study was reduced by the sampling scheme (five-year age strata, 50-54 through 75+), which minimized the negative impact of low response rates among the oldest old. In our age-stratified sample of Rochester, Minnesota women, response rates for age-groups 50-59 and 60-69 years were 70.1% and 68.9%, respectively, or better than all but three of the EVOS centers. However, our response rates for women aged 70-79 and/>80 years were only 55.9% and 56.8%, respectively, for an overall response rate of 61%, better than only two-thirds of the EVOS centers. Because of the greater weight given to older women in our study, the age difference between responders and non-responders was greater (median, 60 versus 67 years). This is important, of course, because older women have more fractures. Thus, fracture prevalence was greater among the nonresponders (Table 1). The prevalence of clinically detected vertebral fractures, for example, was 16% among 232 non-responders compared to 9% among the 305 responders aged 30 years and over (p = 0.02). After adjusting for the differences in age, vertebral fracture prevalence was 30% less among the responders (odds ratio, 0.7; 95% C.I. 0.4-1.2). Some other differences were as great. Even after adjusting for age, for example, the responders were nearly five times more likely to have had bilateral oophorectomy (7.9% versus 1.8%) but only half as likely to have had a history of hyperthyroidism (1.6% versus 3.5%). Responders were much less likely to have had renal failure (0.3% versus 6.0%). A further 16% of the non-responders were ineligible for study mainly because of dementia. Frail and sick individuals such as

applied, in the admission of some cursory remarks on empiricism ; a subject which affords an ample revenue to the state, gives a bias for medicine in the community, and ultimately tends to promote the interests of the profession, by exciting and extending this propensity, and which rather increases than diminishes the number of patients of the regular practitioner, as quack medicines are generally calculated to amuse without curing the sick. Imagination is the most active passion of the mind, at the same time it is one of the least stable ; so that the persons most addicted to quackery are, such as are under the influence of more imaginary than real disease, the nervous, hypochondriac, and hysteric. They are objects, however, of compassion, and their sensibilities demand pity. They find solace in variety, and their minds are soothed and charmed by novelty; the benevolent will therefore be disposed to excuse and indulge them in a propensity so conducive to mental comfort. The greatest relief, indeed, is experienced by the medical professor, who is tired with importunity to remove imaginary evils, or to subscribe to unnecessary and unavailing recipes.
There is, in the human mind, a love for novelty and a predilection for the marvellous. It is predominant in tnoral and sometimes even in virtuous pursuits, hence the enthusiasm On Quacks and JEmpiricisnt. enthusiasm in religious, and the ardour in politics4 the first to the excess of mania and suicide, and the latter to deliberate murder by duelling; It is not surprizing there*fore that the love of the marvellous should extend to objects that respect health, when so many flattering promises (however fallacious) are held up to the desponding invalid, whose weakness leads him to credulity, and his* distempered imagination to hope and confidence.
A circumstance highly conducive to quackery is, the overflowing wealth of this country. Persons of fortune ?sufficient to enable them to live without industry, (which is itself a disease, or the parent of disease) frequently fall into a state of ennui, which would become insupportable> Were it not that in moral, as well as jn physical evils, a. disease when it shall have arisen to a certain extent, for*tunately tends to cure itself; hence the privileged orders, those exempted from labour by their affluence, attempt to Ward off the consequent evils, by cards, plays, parties, clubs, public breakfasts, public dinners, and nocturnal amusements; others, of a more hypochondriac temperament, enjoy the luxury of novels and patent medicines, and after satiety has been gratified by variety, occasionally repose upon regular practitioners, till the doctor, wearied out by importunity, and the patient by imaginary or real maladies, reverts to new nostrums, or by visiting fashionable watering places, dissipates care, and diverts ennui, at least for a season.
It is not my intention at present to convey the reader to times of yore ; but I have Jived to have known a distinguished group of quacks, whose names and remedies are now scarcely remembered; or if the latter are recollected, it is to mark the loss of their celebrity. Ward, about the middle of the last century, still lives in recollection, by the formulae of medicines, bequeathed to a charitable purpose ; whilst he was a prominent character, lived a Dr?
Ilyan, an obscure physician, of merit and abilities; but without professional character himself, he was the means of raising that of Ward, by giving or rather selling to him his nostrums, and by which Ryan must have raised a considerable sum, as he assured me he received two hundred pounds for his white drop alone. Soon afterwards ?e Fevre from Liege appeared as a blazing star, and in a few months realized in this credulous country about ten thousand pounds, by pretending to cure the gout, a delusion he carried on by giving small doses of white vitriol.
Although he was ignorant of medicine,, he possessed the common "556 On Quaclis and Empiricism. common sense to know that the gout makes its attack principally in the spring and autumn, on which account he commenced his operation in the spring period, when the violence of the attack would be naturally receding, and lie had the prudence to quit England (carrying home his fortune) before the autumnal return of the disease. Some empirics have succeeded by the fascination of a title to a nostrum, thus the Ephractic Pill of the Dispensary, afforded a fortune to Dr H. by vending it under the name of the Female Fill, whence of course it must be inferred to be applicable to the case of every female. Daffy's elixir, was the old elixir salutis, now tincture of senna. , Godbold's syrup is honey and vinegar, the composition of which was known before Godbold was born, as the simple ox}'iriel of the shops.
In Surgery, quackery has been extended with equal profit to the empiric, although perhaps with more injury to the patient. A few years ago, Capt. *** came from America, with the patronage of numerous recommendation of being able radically to cure cancer; and although he never cured one, he is said to have pocketed ten thousand guineas of devoted English dupes.
This afforded encouragement to a more recent adventurer, a pupil of Dr. Rush, and really recommended by him; and whose reputation was so high in cancer empiricism, as to induce a lady here to offer him one thousand pounds to cross the Atlantic as a douceur. Weak minds are apt to estimate the value of an object by the difficulty ol acquiring it; and the eclat of a single patient, although 110 advantage could be gained, except by the American adventurer, suddenly raised his reputation, and acquired him a fortune, which the sagacity of his countrymen never would have conferred.